Feds crack down on urology billing fraud, abuse

Washington—With all of the pressure on the federal government to curtail spending, the U.S. Department of Health and Human Services (HHS) is not kidding around when it comes to investigating and prosecuting Medicare fraud and abuse.

In Houston, a federal grand jury in May returned a three-count indictment against urologist Hossein Lahiji, MD, and his wife, attorney Najmeh Vahid Lahiji, charging that the Lahijis conspired to defraud multiple health care benefit programs, including Medicare and Medicaid and major health care insurers, from January 2003 through Feb. 24, 2012.

The indictment alleges they submitted false and fraudulent claims in connection with the use of unlicensed, unqualified medical personnel and billed for medical services not rendered. The indictment says the Lahijis submitted claims for urology services performed by Dr. Lahiji when he was actually traveling outside the state of Texas and outside the U.S. The services were performed, according to the indictment, by medical assistants without supervision.

The charges against Dr. Lahiji are just an example of the government's determination to crack down on health care fraud and abuse. More headlines can be expected and urologists may find themselves contacted as federal agents investigate everything from upcoding, making false claims regarding evaluation and management (E&M) services, and imaging services.

In early May, the HHS Office of Inspector General (OIG) issued a report stating that physicians are billing Medicare for far more intensive E&M services than they did a decade ago. In 2010, OIG identified 1,669 physicians who consistently billed higher-level E&M codes within a visit type at least 95% of the time. Those physicians represented less than 1% of all physicians who performed E&M services in 2010, and OIG said they "substantially differed from others in their billing of E&M codes." Most other physicians billed for those codes 53% of the time, OIG said.

When OIG broke down those potential violators by specialty, only 1.2% were urologists. Leading the list was internal medicine, 19.8%; family practice, 12.2%; emergency medicine, 9.9%; nurse practitioners, 4.4%; obstetrics and gynecology, 4.3%; and cardiovascular disease/cardiology, 4.0%.

The report said Medicare paid approximately $108 million for E&M services performed by physicians who consistently billed the two highest-level E&M codes in 2010.

"As a result, Medicare paid on average $205 more per beneficiary and $43 more per E&M service to physicians who consistently billed higher-level codes," OIG said. Of those 1,669 physicians, 916 billed the two highest-level codes 100% of the time, resulting in $54 million in Medicare payments. OIG also said that beneficiaries treated by those billing at the highest levels had diagnoses similar to those treated by other physicians.

As a result of its investigation, OIG said the Centers for Medicare & Medicaid Services should continue to educate physicians regarding appropriate coding, in the form of letters, face-to-face meetings, telephone conferences, seminars, and workshops. OIG also recommended that CMS encourage its contractor to review physicians' billing for E&M services and produce comparative billing reports. CMS should also conduct additional reviews of physicians who consistently bill higher-level E&M codes to ensure their claims are appropriate, OIG said. If inappropriate claims have been paid, CMS should take steps to recover those payments.

OIG said it has provided CMS the list of physicians who consistently billed at the highest levels in 2010 and will also consider those physicians for further review.

Meanwhile, urologists can expect OIG to hone in on imaging services as part of its effort to uncover unnecessary expenditures.

In its fiscal year 2012 work plan, OIG said it would review Medicare payments for Part B imaging services "to determine whether they reflect the expenses incurred and whether the utilization rates reflect industry practices."

It is not enough to identify overpayments and report them to CMS, according to OIG. Late in May, OIG said that as of Oct. 8, 2010, CMS had not collected the majority of overpayment amounts identified in 1,564 audit reports, with sustained overpayment amounts totaling $83.3 million and $896,000 for eight reports. In addition, OIG said it could not verify the $84.2 million that CMS reported collecting.

OIG made several recommendations to CMS, including pursuing legislation to extend the statute of limitations so the recovery period is sufficient and ensuring that its Audit Tracking and Reporting System (ATARS) is updated to accurately reflect recommendations.

So not only is OIG keeping a wary eye on health care providers, hospitals, nursing homes, sellers of durable medical equipment, and more, but the agency is also staying after CMS to make sure it follows through on its recommendations.

It's a good thing that very few urologists are in the ranks of top potential abusers, as reported by OIG.

Bob Gatty, a former congressional aide, covers news from Washington for Urology Times.